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Pituitary apoplexy within a macroprolactinoma

Nature Clinical Practice Endocrinology & Metabolism volume 4, pages 635–641 (2008)Cite this article

Abstract

Background A 61-year-old lady was admitted to hospital with sepsis due to a urinary tract infection. Three days after admission, she suddenly started to have severe headache with visual disturbance and right third nerve palsy. Urgent magnetic resonance angiography excluded internal carotid artery aneurysm but showed a large lesion extending superiorly from the clivus towards the right cerebral peduncle, which was confirmed by a CT scan of the brain. The lesion was initially thought to be a primary or a metastatic brain tumor. CT scans of the thorax, abdomen and pelvis showed no evidence of metastatic disease. MRI scan revealed a huge pituitary adenoma containing hemorrhage. Subsequent pituitary function tests indicated a grossly elevated serum prolactin level and hypopituitarism.

Investigations Magnetic resonance angiography of the head; CT scans of the brain, thorax, abdomen and pelvis; MRI scan of the pituitary gland; and baseline and dynamic anterior pituitary function testing.

Diagnosis Pituitary apoplexy within a macroprolactinoma.

Management Steroid replacement, careful control of fluid and electrolyte balance and conservative nonsurgical management with the dopamine agonist cabergoline resulted in resolution of the patient's headache, improvement of the third nerve palsy and subsequent normalization of the prolactin level, with reduction in size of the prolactinoma on MRI scan.

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Figure 1: Right partial ptosis and strabismus due to right third nerve palsy.
Figure 2: A magnetic resonance angiography scan (taken 2 days after the onset of symptoms) demonstrating a large lesion (arrow) extending from the clivus superiorly above the pituitary fossa, with distortion of the right cerebral peduncle.
Figure 3: CT scan (taken 6 days after the onset of symptoms) demonstrating an enhancing lesion (arrow) with cystic area expanding from the clivus and extending into the suprasellar cistern and right cerebral peduncle.
Figure 4: Nonenhanced MRI scans (taken 12 days after the onset of symptoms) demonstrating a large pituitary macroadenoma extending to the suprasellar region on the right side and containing hemorrhage (arrows).
Figure 5: Nonenhanced MRI scan at 12-month follow-up demonstrating noticeable reduction in size of the pituitary macroadenoma following treatment with cabergoline.
Figure 6: An algorithm for the management of pituitary apoplexy.

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Acknowledgements

Désirée Lie, University of California, Irvine, CA, is the author of and is solely responsible for the content of the learning objectives, questions and answers of the Medscape-accredited continuing medical education activity associated with this article. We thank the patient for giving her written consent to the use of her photograph and other medical images in this Case Study.

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Authors and Affiliations

  1. A Watt is Acting Consultant Endocrinologist at the Department of Endocrinology, Royal Devon & Exeter Hospital, Exeter,

    Alastair Watt

  2. L Pobereskin is a Consultant Neurosurgeon at the Department of Neurosurgery, Plymouth and B Vaidya is a Consultant Endocrinologist and Honorary Senior Clinical Lecturer at the Department of Endocrinology, Derriford Hospital, Royal Devon & Exeter Hospital and Peninsula Medical School, Exeter, UK.,

    Louis Pobereskin & Bijay Vaidya

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  1. Alastair Watt
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Correspondence to Bijay Vaidya.

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Watt, A., Pobereskin, L. & Vaidya, B. Pituitary apoplexy within a macroprolactinoma. Nat Rev Endocrinol 4, 635–641 (2008). https://doi.org/10.1038/ncpendmet0968

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